Common Skin Disorders Of The Penis
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Common Skin Disorders Of The Penis

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Review of penile skin disorders

Review of penile skin disorders

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Common Skin Disorders Of The Penis Presentation Transcript

  • 1. Common skin disorders of the penis Main reference: BJU International 2002 S.A. BUECHNER Department of Dermatology, University of Basel, Switzerland Urology Conference Presented by: Ahmad Kharrouby PGY3
  • 2. Outline
  • 3. Outline
    • A-Viral infections
      • Genital warts
      • Genital herpes
    • B-Bacterial ulcerative lesions
      • Chancre ( Syphilis)
      • Chancroid (H. ducreyi )
    • C-Infestations
      • Scabies
      • Pediculosis pubis
    • D-Cutaneous diseases
      • Psoriasis
      • Lichen planus
      • Penile lichen sclerosus
      • Contact dermatitis
      • Fixed-drug eruptions
    • E-Balanitis and balanoposthitis
      • Plasma cell balanitis
      • Balanitis circinata
    • F-Premalignant and malignant genital tumours
      • Giant condyloma
      • Bowen’s disease
      • Bowenoid papulosis
      • Erythroplasia of Queyrat
      • Penile SCC
  • 4. A-Viral infections 1- Genital warts 2-Genital herpes
  • 5. 1- Genital warts
  • 6. A-Viral infections 1- Genital warts
    • The most common sexually transmitted disease
    • Caused by HPV
    • 1 percent of all sexually active adults have genital warts
    • 10% can be documented to have active HPV by PCR
    • Elevated genital warts, condyloma acuminata, are due to low-risk HPV types (usually 6 and 11)
    • Occur mostly under the prepuce, and on the penile shaft
  • 7. A-Viral infections 1- Genital warts
    • There are three major types of anogenital warts:
      • Condyloma acuminata are pedunculated, cauliflower-like, skin-coloured to reddish verrucous papules
      • Dome-shaped, usually flesh coloured papules
      • Flat warts are flat-topped papules which may vary in colour from pink-red to reddish-brown
  • 8. Multiple papular pigmented condylomata acuminata on the penile shaft
  • 9. Numerous whitish condylomata acuminata on the tip of the penis
  • 10. A-Viral infections 1- Genital warts
    • Current treatments can eradicate only the warts and not the virus, recurrence is very common (>25%)
    • There are 2 basic forms of therapy:
      • Patient applied
      • Health-care worker applied
  • 11. A-Viral infections 1- Genital warts
    • Patient-applied treatment:
      • Podophyllotoxin is applied twice daily for 3 days per week for 6–10 weeks
      • Imiquimod is an immune modulator that results in the local production of interferon, It is applied once daily for three times per week
  • 12. A-Viral infections 1- Genital warts
    • Physician-applied treatments include:
      • Liquid nitrogen cryotherapy
      • Electrocautery
      • Laser therapy
      • Intralesional or systemic immunotherapies
  • 13. 2- Genital herpes
  • 14. A-Viral infections 2- Genital herpes
    • The most common cause of genital ulcers
    • Is an incurable and recurrent viral infection
    • Sexually transmitted
    • Is predominantly caused by HSV type 2
    • HSV-1 is responsible for 5–30% of cases of first-episode
    • After infection, the viral genome remains in a latent state in the nuclei of sensory neurons for the life of the host
    • Genital HSV-1 infections are usually less severe and less prone to recur than those caused by HSV- 2
  • 15. A-Viral infections 2- Genital herpes
    • Appears as macules and papules, followed by vesicles, pustules and ulcers
    • Systemic complaints including fever, myalgias and lethargy may be present, but are rare
    • Patients will often have accompanying tender lymphadenitis
  • 16. Genital herpes; grouped vesicles and erosions are located on the penis shaft and scrotum
  • 17. A-Viral infections 2- Genital herpes
    • Recurrent episodes are less severe and undergo rapid involution within 5– 10 days
    • Recurrence rate reach 90% in HSV 2
    • Diagnosis can be confirmed by virus isolation in cell culture or by PCR
  • 18. A-Viral infections 2- Genital herpes
  • 19. B-Bacterial ulcerative lesions 1-Chancre ( Syphilis) 2-Chancroid (H. ducreyi )
  • 20. 1- Chancre ( Syphilis)
  • 21. B-Bacterial ulcerative lesions 1- Chancre ( Syphilis)
    • Caused by the spirochete Treponema pallidum
    • Occurs during the first stage of syphilis i.e.Primary syphilis
    • Is an ulcerative lesion at the site of spirochete entry
    • Appears about 3-4 weeks after infection
    • The chancre is usually hard and painless
    • The lesions typically clear after about a month without scarring
    • Serologic tests are often negative when the chancre first appears but become reactive in the following 1-4 weeks
  • 22. Syphilitic chancres may appear on or around the genitals
  • 23. B-Bacterial ulcerative lesions 1- Chancre ( Syphilis)
    • Definitive diagnosis involves demonstration of Treponema pallidum by darkfield microscopy in lesions
    • Treatment of primary syphilis is Benzathine penicillin G, 2.4 million units IM as a single dose
  • 24. 2-Chancroid (H. ducreyi )
  • 25. B-Bacterial ulcerative lesions 2-Chancroid (H. ducreyi )
    • Chancroid is an acute ulcerative disease, often associated with inguinal adenopathy (“bubo”)
    • H. ducreyi , a gram-negative facultative bacillus, is the cause
    • Definitive diagnosis of chancroid requires identification H. ducreyi , on specialized culture media that are not widely available
  • 26. B-Bacterial ulcerative lesions 2-Chancroid (H. ducreyi )
    • In practice, a probable diagnosis of chancroid may be based on the following:
      • the patient has a painful genital ulcer
      • there is no evidence of T. pallidum by darkfield examination
      • an HSV test is negative
      • the clinical appearance is typical
  • 27.  
  • 28. B-Bacterial ulcerative lesions 2-Chancroid (H. ducreyi )
    • Treatment of chancroid is Azithromycin, 1 g as a single oral dose
    • or ceftriaxone, 250 mg as a single IM dose
    • or ciprofloxacin, 500 mg orally twice a day for 3 days
  • 29. C-Infestations 1-Scabies 2-Pediculosis pubis
  • 30. 1-Scabies
  • 31. C-Infestations 1- Scabies
    • Caused by human mite Sarcoptes scabiei
    • Causes a severely pruritic, widespread eruption
    • Very itchy papules or nodules with a central crust on the penile shaft or glans and on the scrotum
    • In adults, scabies is a sexually transmitted disease
  • 32. Scabies; multiple erythematous papules
  • 33. C-Infestations 1- Scabies
    • Treatment consists of overnight application of 5% permethrin cream to the whole body from the neck down
    • To be repeated in 1 week
    • All sexual partners should be treated simultaneously
    • All clothing, bedding, and towels should be washed and heat dried
  • 34. 2-Pediculosis pubis
  • 35. C-Infestations 2-Pediculosis pubis
    • Pediculosis pubis may be sexually or nonsexually transmitted
    • Itching may be intense
    • The nits are found on the hair shafts in the pubic area and the eyelids
  • 36.  
  • 37. The nits are found on the hair shafts in the pubic area and the eyelids
  • 38. C-Infestations 2-Pediculosis pubis
    • Treatment consists of application of permethrin 1% crème rinse applied for 10 minutes then washed off
    • To be repeated in 1 week
    • All hairy areas contiguous with the genital area should be treated
    • The sexual partner(s) should be treated also
    • All clothing, bedding, and towels should be washed and heat dried
  • 39. D-Cutaneous diseases 1-Psoriasis 2-Lichen planus 3-Penile lichen sclerosus 4-Contact dermatitis 5-Fixed-drug eruptions
  • 40. 1-Psoriasis
  • 41. D-Cutaneous diseases 1- Psoriasis
    • A solitary plaque may present on the glans penis, leading to confusion with high-grade dysplasia (erythroplasia of Queyrat)
    • Itching may be intense or nonexistent
    • The diagnosis usually can be made by inspection and by noting other areas of involvement such as the scalp, elbows, knees, and nails
  • 42. Psoriasis; red scaly patches on the glans penis
  • 43.  
  • 44. D-Cutaneous diseases 1- Psoriasis
    • Hydrocortisone cream, 1%
    • plus an imidazole cream (clotrimazole, 1%) is usually efficacious
    • Washing the glans after intercourse is critical in controlling penile psoriasis
  • 45. 2- Lichen planus
  • 46. D-Cutaneous diseases 2- Lichen planus
    • Lichen planus may affect the glans penis
    • The genitalia may be the only site of involvement
    • The lesions are polygonal, violet-hued, flat-topped papules, with shiny surfaces
    • Lesions may be asymptomatic, pruritic, or painful if eroded
    • A biopsy may be required
  • 47. Lichen planus; numerous annular violaceous papules on the glans penis
  • 48. D-Cutaneous diseases 2- Lichen planus
    • Topical corticosteroids and topical tacrolimus 0.1% ointment
    • The disease may disappear after months to years
  • 49. 3- Lichen Sclerosis
  • 50. D-Cutaneous diseases 3- Lichen Sclerosis
    • LS almost inevitably involves the anogenital regions, where severe pruritus or painful erosions may develop
    • LS of the glans penis may lead to phimosis and urethral stenosis
  • 51. Lichen sclerosus; a typical white sclerotic ring at the tip of foreskin
  • 52. D-Cutaneous diseases 3- Lichen Sclerosis
    • Topical steroids are the treatment of choice
    • An initial trial should be 6 weeks of treatment
    • Once the patient is in remission, milder steroids or bland emollients may be used for maintenance
  • 53. 4- Contact dermatitis
  • 54. Cutaneous diseases 4- Contact dermatitis
    • True allergic contact dermatitis is pruritic, erythematous, edematous, and weepy
    • Possible causes are hygiene products, condoms, and plants
  • 55. D-Cutaneous diseases 4-Contact dermatitis
    • Twice-daily cool water compresses
    • Followed immediately by the application of a mild topical steroid (1% hydrocortisone ointment)
  • 56. 5- Fixed-drug eruptions
  • 57. D-Cutaneous diseases 5- Fixed-drug eruptions
    • Fixed drug eruption, due usually to laxatives sulfonamides, or NSAIDs, commonly presents on the genitalia
    • Two percent of all genital ulcers are fixed drug eruptions
    • Lesions often begin within a day of drug exposure and present as bright red to violaceous macules that quickly blister and erode
  • 58. Fixed drug eruption caused by ingestion of trimethoprim-sulphamethoxazole, showing the dusky erythematous solitary lesion
  • 59. D-Cutaneous diseases 5- Fixed-drug eruptions
    • The erosion is superficial and broad (usually >1 cm)
    • Fixed drug eruption occurs in the same site with each exposure to the same drug
    • Treatment is to stop the offending medication
  • 60. E-Balanitis and balanoposthitis 1-Plasma cell balanitis 2-Balanitis circinata
  • 61. 1-Plasma cell balanitis
  • 62. E-Balanitis and balanoposthitis 1- Plasma cell balanitis
    • Is a benign chronic balanitis of unknown origin
    • The condition usually manifests in middle-aged or elderly uncircumcised men
    • Plasma cell balanitis is characterized by a solitary red-orange plaque of the glans and prepuce
    • The plaque surface is shiny and smooth, slightly moist
  • 63. Plasma cell balanitis; a well circumscribed, shiny red plaque
  • 64. E-Balanitis and balanoposthitis 1- Plasma cell balanitis
    • The disease tends to be chronic and may persist for months to years
    • It is important to verify the diagnosis by biopsy
    • The histopathology is characteristic showing a band-like infiltrate of plasma cells
  • 65. E-Balanitis and balanoposthitis 1- Plasma cell balanitis
    • The treatment of choice for is circumcision
    • Temporary relief is usually achieved by a topical steroid
  • 66. 2- Balanitis circinata
  • 67. E-Balanitis and balanoposthitis 2- Balanitis circinata
    • Balanitis circinata is a mucocutaneous manifestation of Reiter’s syndrome
    • A multisystem disease, that is clinically characterized by the triad of nongonococcal urethritis, arthritis and conjunctivitis
    • Manifests as a well-demarcated, moist, erythematous plaque with a ragged or scalloped white border on the glans penis
  • 68. Balanitis circinata; well-demarcated, erythematous plaque with a ragged border on the glans penis
  • 69. F-Premalignant and malignant genital tumours 1-Giant condyloma 2-Bowen’s disease 3-Bowenoid papulosis 4-Erythroplasia of Queyrat 5-Penile SCC
  • 70. 1-Giant condyloma
  • 71. F-Premalignant and malignant genital tumours 1- Giant condyloma
    • Giant condylomata acuminata are cauliflower-like lesions arising from the prepuce or glans
    • Most cases are caused by infection with low risk HPV 6 and 11
    • These lesions may be difficult to distinguish from well-differentiated squamous cell carcinoma
    • Most represent a subtype of low-grade SCC
    • Deep biopsies are needed
  • 72. Giant condylomata acuminata are cauliflower-like lesions arising from the prepuce or glans
  • 73. 2-Bowen’s disease
  • 74. F-Premalignant and malignant genital tumours 2-Bowen’s disease
    • Bowen’s disease is a squamous cell carcinoma in situ typically involving the penile shaft
    • The lesion appears as a red plaque with encrustations
    • Surgical excision is the best treatment option for small lesions, preferably by cryosurgery or CO2 laser
  • 75. 3- Bowenoid papulosis
  • 76. F-Premalignant and malignant genital tumours 3- Bowenoid papulosis
    • Similar to Bowen’s but multiple papules instead of plaques
    • Bowenoid papulosis is a high grade intraepithelial lesion
    • Bowenoid papulosis is characterized by flat, skin-coloured, pink or often hyperpigmented papules
    • Is strongly associated with HPV 16
    • Occurs mainly in young sexually active adults, with lesions on the glans and prepuce
  • 77. Bowenoid papulosis; multiple flat pigmented papules
  • 78. F-Premalignant and malignant genital tumours 3- Bowenoid papulosis
    • The most effective treatment is excision of the papules
    • However, cryosurgery with liquid nitrogen and carbon dioxide laser are the most frequently used method
  • 79. 4-Erythroplasia of Queyrat
  • 80. F-Premalignant and malignant genital tumours 4-Erythroplasia of Queyrat
    • Is a velvety, red lesion with ulcerations that usually involve the glans
    • Microscopic examination shows typical, hyperplastic cells in a disordered array with vacuolated cytoplasm and mitotic figures
    • Surgical excision is the treatment of choice, but topical 5-fluorouracil and the CO2 laser may also be used
  • 81. Erythroplasia of Queyrat is a velvety, red lesion with ulcerations
  • 82. 5-Penile SCC
  • 83. F-Premalignant and malignant genital tumours 5-Penile SCC
    • Of all cancers affecting the penis 95% are SCC
    • The disease is rare
    • The age at the onset of penile SCC has a wide range (20– 90 years) with a peak around the fifth decade
    • Risk factors are
      • Phimosis
      • Lack of circumcision
      • Chronic inflammatory conditions
      • Multiple sexual partners
      • HPV infection
  • 84. F-Premalignant and malignant genital tumours 5-Penile SCC
    • The clinical appearance of penile SCC varies from
      • erythematous plaque
      • induration
      • verrucous lesions
      • exophytic lesions
      • irregularly shaped mass
    • As it increases in size, superficial ulceration, necrosis and bleeding may become evident
  • 85. Penile SCC presenting as an erythematous, nodular, erosive lesion on the glans penis
  • 86. Squamous cell carcinoma exophytic erosive lesion with evident keratanization
  • 87. F-Premalignant and malignant genital tumours 5-Penile SCC
    • The treatment of penile SCC depends on tumour staging and includes surgery, radiotherapy, laser surgery and chemotherapy
  • 88. References
    • BJU International (2002), Common skin disorders of the penis, S.A. BUECHNER, Department of Dermatology, University of Basel, Switzerland
    • Smith’s General Urology, Seventeenth Edition, Skin Diseases of the External Genitalia, Timothy G. Berger, MD
  • 89. Thank You